Doctor, Am I Going to Die?

20131002-230931.jpgDo you remember the Seinfeld episode where Kramer acts like he has gonorrhea for medical students? Well, we really did have actors in medical school. One of the actors I remembered posed as a patient receiving the news of cancer from me, then a medical student. I walked into the room, not even knowing what kind of cancer she had. I sat down and said, “I have the results of your test. It shows cancer.” She started crying and then I had no idea what to say. I asked, “Are you going to be okay?” The feedback I got was not the greatest. I could’ve been more empathetic… I thought, I hope I never have to do this for a living.

Fast forward to last week. I had a young woman in her forties whose breasts became rock hard 1 month ago. Since then, she had developed facial paralysis in half her face andwas having terrible body aches. She went to the emergency room a few days prior to seeing me and they could only reassure her that she had not had a stroke.

So here I am, meeting her for the first time for a biopsy. She looks horribly ill. I begin the same way I always do, explaining the procedure and what she can expect to feel. She doesn’t really seem to care. She is too focused on the discomfort she is feeling in the rest of her body. As I start to give her her numbing medication, she begins bleeding instantly. I stop and hold some pressure. It appears I am going to be here a bit longer than I really want to be. As I start to place the biopsy needle into her breast, she asks me, “Do I have cancer?”

Not really wanting to have this conversation while performing a difficult biopsy, I reply, “Do you really want to know what I think?” Of course she replies, yes. “I think you have lymphoma, which is a type of cancer.” She starts breaking down crying. I have to continue on with the biopsy. After what feels like hours of sobbing, she then asks me, “Am I going to die?”

The truth was maybe. I have seen women with lymphoma of their breasts die. I reply, “I don’t know.” More sobbing. I then say to her, “I know there is nothing I can say that will make you feel better now. All I can say is that I will get you an answer. Once we have that, we can move forward and get you treatment.”

I am not going to lie and say I wasn’t happy to leave the room when I was done. But once I left the room, I just went on with my day and didn’t really think twice about it. That was until yesterday, when my rep who sells me the biopsy needles (who was in the room during the whole procedure) said, “Wow, that was a really emotional case the other day. That was one of the toughest situations I have seen and you handled it really well.” When I took a step back and thought about it, I tried to picture how I might’ve handled it when I first started. I probably would have just done the procedure and tried to get out of the room as soon as possible.

Over the years, I have accepted the fact that I will never know what it feels like to be on the other side. I will never understand the fears that go through my patient’s heads. The only thing I can do in that moment is to offer support. I can’t promise them that they will live, but I can promise them that I will take care of them and always be there for them. That is what working with cancer for 5 years has taught me, not some actress in medical school. That is the art of medicine.

Cancer a second time

Stacy was woman in her early fifties who in for a routine mammogram.  She was diagnosed with DCIS 2 years prior and treated with lumpectomy and radiation and was currently on Tamoxifen.  Because she was only 2 years out from her diagnosis, I read her mammogram while she was there.

I opened up her study.  Oh no, those calcifications don’t look good.  I immediately knew that her DCIS had come back, but this time in two spots.  I went in to talk to her and her husband.  I could immediately tell that she was a nervous wreck.

“There are two new areas of calcifications in your right breast that look worrisome.  We need to do a biopsy to find out what is causing the calcifications.”

She breaks down hysterically and starts crying.  She screams, “I can’t go through this again!”  As her husband tried to help calm her down, I stood there awkwardly, not knowing what else I could say.  I couldn’t say anything that was going to make things better at that moment.  So, I quickly passed her on to my patient navigator to schedule an appointment.

I saw Stacy again a few days later for her biopsy.  She is much more composed and her husband is with her again.  We finish the biopsy and at the end, I thought, I’d better prepare her for what is to come.

“If the biopsy comes back benign, I am not going to be satisfied with those results.”

What do you mean?

“I am really worried that those calcifications are due to DCIS.  If the results come back benign, I would want to be extra sure that they were benign by having a surgeon take out a larger sample and make sure that I didn’t miss something.”  It started to sink in.

If it’s cancer again, I am going to need a mastectomy.

She starts crying again.  After a moment, I asked her what was going through her head.

I don’t want my husband to find me unattractive.  Men leave women for those things.

Ok, I didn’t see that one coming.  With her husband being with her every step of the way, I didn’t think that would be a concern to her.  I reassured her that breast reconstruction had come a long way and that her husband obviously cared enough about her to come to all her appointments.

She asked me to tell her husband what I had told her.  When I did, she started crying again, asking her husband how they were going tell the kids. I said, “I am sorry.  Is there anything else I can do for you right now?”

“No.  Just find a cure!” her husband barked at me.

I will never forget the look on his face when he said that to me.  I felt so small and powerless.  As a doctor, I was supposed to help people and yet it didn’t seem like I could help either one of them at all.  Again, I quickly left the room.

Stacy did ended up having DCIS, the kind that probably would’ve eventually become invasive cancer had it been left alone.  She had a breast MRI and it turned out she had DCIS in the other breast too.  She decided to have bilateral mastectomies.

Though I often see the fear and anger that patients go through, I got to experience firsthand the anger that family members have when their loved one gets cancer.  It reminded me that it wasn’t just the patients who go through emotional roller coasters with cancer, and the roller coaster can be even bigger the second time around.

Just find a cure… I wish I could…